So, welcome everyone to this session. It's a session in a different format than usually, though the speakers do not have slides, but it's for discussion, and I encourage all of you to ask questions to the microphone or via the platform, and we'll show you how in a moment. My name is Laurent Max, I'm from the Montreal Heart Institute in Canada. I'll be co-chairing this session with Susan Eisenberg from California here in the United States. So our panel is that we'll be there to discuss the different topics that we've prepared for them, and the point is really to come up with tips and tricks and questions you may have in your workflow of AF ablation. They are here to answer those questions and to see their perspective on the different topics. So the panel that we have today is Moussa Mansour from Boston, United States. We have Melanie Gunawardene from Germany. We have Andrea Natale from USA, and Pierre Jais from Bordeaux in France. Roland, unfortunately, will not be here. He was doing a life case from Germany, so I don't think he'll make it to the meeting here. So I'm going to present my co-chair, which is Susan. I presented this from California, and she's going to come up with the learning objective for this meeting. Thank you. Thank you so much. So our objectives for today are to try and review the AF ablation workflow, in particular looking at the planning of procedures, your catheter selection. We're going to talk a little bit about different energy modalities and whether people are selecting certain modalities for certain cases or combining certain modalities. We're going to identify pros and cons of innovative ablation strategies to optimize safety and success of the ablation. And then finally, we'd like to revise potential ablation strategies during the redo procedure for persistent AF or paroxysmal patients who have recurrences. So we're going to try and address all those issues as we go through each kind of question. We want it to be a very open format, so you can feel free to ask questions. And to do so, you can also do it online. So I encourage you to scan the QR code that you have there so you can ask your question via the platform, and we can get them on the iPad here. But it's really informal, so we want you to participate. You can stand up and ask the question as we go along in the discussions. So we'll have five discussion points that we've prepared, but if you have additional discussion points, bring them up and we can ask our experts to discuss these points. So the first discussion point that we've planned with Susan is to discuss the planning and procedural ablation workflow according to the ablation technology used. The idea behind that is when we switch to PFA technology, which is limited to pulmonary vein in some jurisdictions, how do you plan your procedure in advance and how do you plan them during the case and the setup as well? So the first aspect would be, and we'll have to see the opinion, so when you switch to PFA approach, for example, in your cases, were you limited in some sort, or not maybe? So how do you schedule those cases? Because we had an issue in our hospital about that. So you know, if there's a patient is scheduled, but it was scheduled like a PFA varipulse case, for example, and then we find that there were flutter recorded as well. So how do you, what is your input on that? And how did you change your strategy of planning those procedure in your sites? So we can start, whoever is ready to go. So Pierre, did you change anything in your strategy? I'm not ready. Not really. The thing I keep doing for every patient is that I see them at the outpatient consultation before scheduling the ablation, and this remains through whatever energy I use, because I had, you know, sometimes you're in a rush, you have no time for that, and then if there is a complication, it's going to be terrible. So that's the first thing I like to say, and I keep doing, even though it's not always easy. Now because of PFA, the thing that has changed to me is that I always check the renal function of my patient during this outpatient consultation, and I take a note so that I'm not surprised when it comes. And this is important in the fact that this will impact the strategy I'm going to use if the renal function is kind of impacted already, like DFG around, sorry, right around in English, glomerular function is reduced, and if it's a persistent AF, then I will carefully rethink my ablation strategy to potentially limit to permyovene isolation or things like that. And then comes the very difficult question of some technologies that require the use of general anesthesia, which means that you have to have access to the anesthetist, which in France is still not that easy, so that would also impact the way we proceed. I'm fortunate enough to have some qualifications in resuscitation, so I feel comfortable doing my boluses of propofol without general anesthesia, and I use that for, definitely when I work with FAPLs, but SPHERE 9 is different. SPHERE 9 requires a higher degree of sedation, in my opinion, particularly because if you don't do that, you have motions that will induce map shifts, and so you lose the benefit of the mapping system, or you have to remap. And this also impacts my workflow, because if I'm working with SPHERE 9 with no anesthetist, I'm doing the veins one by one. I don't map the entire left atrium before doing the ablation. So all of this matters, and is, I suspect, very viable from one center to the next, or one physician to the next. Thank you, and what would add to the question is the type of anesthesia you're using while we go along. So in our center, we're using deep sedation, 99% of the cases, and I would say our pre-procedural workflow and planning really depends on what kind of procedure we talk about. Is this a first do, for example, or is this a redo procedure, right? Because when you have a redo environment, you need to anticipate certain things, as you said, that there could be atrial tachycardia. So I think it is important to get an ECG documentation of the arrhythmia that you want to treat. I know this is something we say on conferences, like this is mandatory, but I think in clinical practice, you have people referring patients, and you not always get the documentation, at least not before the procedure, or the patients will bring it in in the morning, and then you kind of have to adapt. So we're trying to be very flexible on it, but the better you know the arrhythmia you're targeting. And it is even more important when you start planning for single-shot procedures. So usually we would do the days that we stack them and put them, like, one after another single shot, just to get a little bit through the day and then have more time for complex procedures. And that's, I think, really important to have the arrhythmia. Other than that, we don't really pre-specify anything. There's no imaging that we do except for TE to rule out thrombus. So there's no CT. We don't know the anatomy of the patient. I think what we just recently learned from the single-shot champion trial is that there were 20% of left common veins in the cryo arm, and that's really a limitation to this approach, right? So when you plan, and we still do cryo, not only PFA in Europe. Actually, I think we're doing more than ever. So this is really one of the limitations that we don't really know before, but I would say that it is, but it's just not our practice. Can I just ask why you're doing more than ever cryo? It seems a provocative statement. I know, but it's true. The industry told us that their numbers are rising, and I think it's very different. And one aspect you can't deny is the reimbursement. I think we're getting better with PFA in Europe. It's getting cheaper, but it's still not the same pricing, and I think this is why. But we have to treat so many patients, and we have short waiting lists. We're doing a lot of first-two PBIs all over the country. So I'll touch on three things. First, PFA only. GA versus conscious sedation and only general anesthesia. We tried on a couple of phenopulse cases to do it without general anesthesia, and nobody was happy about it, including the patient. So what type of technology we use? We have five labs, five rooms in the lab, and we have a phenopulse system in all of them and one atherosystem, and we reserved atherosystem for redo cases and cases that we expect are going to need more than just PBI. For PBI only, our first, for patients who we expect are going to need PBI only, our first goal procedure is the phenopulse for them. Andrea? I think our process is very similar to most, is general anesthesia in everybody, and we have in the main center, because we have other hospital where we do cases, but in the main center we have six rooms, soon seven, where we have pharaputs in every room, and we have three athera, which is becoming an issue, so we're going to get the fourth one because everybody's fighting. But I think the selection is very much what Moussa says, for the first time paroxysmal, usually we use pharaputs, even for an early persistent, if we think we're going to do more, or we have a redo, we use athera. Before athera became available, the redo were the only cases where we still use RF with the QDOT, but now with athera we switch completely to that. In terms of additional catheter, we try, obviously with athera we have the mapping system, with the pharaputs we use a mapping system, we used to do the RF with, do the capillary for the non-PV trigger, but if we do a first time typical paroxysmal with no comorbidity, we have a thousand patients with that, so we know how to predict relevance of non-PV trigger, then we don't put the do the capillary anymore, we just do the PVI. I just want to add one more thing, that we try to discourage changing mapping, changing technology in one room. It costs us about 20-30 minutes, if let's say you want to change from one system to the other, it adds about 20-30 minutes to the turnover time, and so we try to discourage that, we plan ahead to keep all the cases in one room using one system. Yeah, that's the thing that many people try using technology. Maybe we can ask the people in the room who's doing deep sedation, maybe raise your hands. Oh, okay, I didn't expect that, so not so many Europeans in the room, and GA? We're in US, so. And so this is GA versus conscious sedation, the other question is mapping system versus no mapping system for fire pulse, so what would be the, and the third question would be ice versus no ice, so Pierre? I don't have the money for ice, and I'm not using any mapping system with fire pulse, I wasn't until FireView came in, and so it's a bit of a change, we're still, you know, assessing the benefit of the cost of the patches, it's slightly more than the purely fluoro procedure, we have very good results with the fluoro only when it comes to PVI, maybe that there is some interest if you want to have the posterior wall in addition to PVI, which we limit to some of the patients with persistent AF, not all of them, some are responding well to PVI only, so my experience, I've been doing plenty of mapping after fire pulse, PVI, and posterior wall, and mitral isthmus, doesn't work well for mitral isthmus, so this is clear, and then the benefit of acute mapping in my experience is almost zero, because there's so much sturning that, in fact, I've stopped quite some time ago to revisit the veins, because they were always isolated, and I couldn't identify any type of signal, whatever, that could be predictive of a PV reconnection, I know that there is ongoing effort using unipolar, different filters, et cetera, maybe there will be a solution to that, at present time, I don't feel it's useful. If I could ask a question of whoever on the panel would like to approach it, we're talking a little bit about pulling multiple technologies, or multiple mapping systems, or multiple catheters, and the expense of the case becomes rather extraordinary, what is everybody doing when they encounter a CTI flutter, or mitral flutter, and it's a PFA case? We do it with PFA, I mean, obviously, with AFERA, it's very easy, because it's a larger single shot, but even with fire pulse, you can do both. So you're doing the CTI with the fire pulse? Yeah. Yeah, we don't change. We do the same. We try not to change, and I think you can use it for most arrhythmias you encounter. With a nitroglycerin protocol ahead of time for coronary spasm? Can you describe your nitroglycerin protocol? Yeah, we use the advantage, the protocol we use for the advantage study, which is 3 milligrams followed by 2, followed by 2, 2 minutes apart, and we give high dose. So 3, then 2. 2 and 2. Then 2. And initially, it may come as a shock to the room, to the anesthesia, but really, we never had any problem with it, and it becomes part of the workflow. We talk to the anesthesiologist to give some neosynephrine before, one minute before, and we never had any issues there. So we have very low threshold of doing it anytime we're near a coronary artery. Maybe I want to be a bit of an opponent here to this, doing this, just because personally I had two very, very severe spasms, and they really scared me, to be honest. And one was despite applying nitro, we published a case in the European Heart Journal case reports, just because I think there's a little bit of uncertainty, because we don't, we're not really sure about application routes. Do we give it IV into the RA? Where do we apply the nitro? I think that the Advantage study, which was with the far point catheter, which is a single tip catheter, looked really good, and I'm happy we're having those studies, but I just want to raise a word of caution here, because you can get into situations that are uncommon for you in an EP environment, and they can get really stressful. You can get heart block, VF when you create a spasm when you apply PFA close to the coronaries, and you just have to be really aware. I think you can do it all, but you have to know the troubleshooting, and it's different than from what we've known before. And also those spasms can occur with a little time delay. This is something you need to know when monitoring your patients, because we were already pulling out sheets, so that was a bit scary. I think that's an important point. Another help can be to put the 12-lead ECG on while you're applying, so you can really monitor your ST elevations, just because we're talking about clinical practices here actually in the session. I think that really helps you to monitor it. So just my opinion on it. It's not that I don't do it, but I don't feel really easy all the time. So do you use the vent spline to do the fluttering? Yeah. Oh, you still do it? Yeah. I try not to, but sometimes you have a flutter occurring, and then, you know. I want to make a comment. Obviously, not to sort of reduce the relevance of spasms, but because it's something real, and so you need to be prepared. And when you have it, the treatment is what Moussa mentioned is a large dose of, not a small dose, a large dose of nitroglycerin to resolve it very quickly. But I have to say, and this could be part of doing this, so there are two agent that we use with anesthesia, gas and paralytic that have some vasodilation effect. I mean, the reality is that we have done with Farapul's more than 4,000 cases and with Affera close to 300 cases. And we had one case with Affera and four with Farapul's where we had some cyst elevation. All of them resolve like with the, not with the preemptive, we give the nitroglycerin after we saw the cyst elevation immediately. So it has to be ready in the room. It's not like, oh, we have the cyst elevation, let's get the nitroglycerin, it has to be there. If you do that, it's not really a stressful happening and it's really, really rare under general anesthesia. Yeah, I share your comments, Melanie, on the fact that we are not yet completely sure of the best strategy. Because it's so simple, if I have a typical flutter, I would still use the panaspline and deliver on the cave, which could be this, yeah. And also because of the cost of opening an extra catheter, this doesn't hold through for perimitral flutters where, again, we had terrible results with the Farapul's. And so we keep doing, so either those patients we anticipate and we have the SPHER9 and we work with SPHER9 and do everything with SPHER9 or by surprise and then we would open a RF catheter. This is what I did like 10 days ago and I've got a thrombosis of the circumflex artery, which is my second or third one in 30 years. So it's not frequent. RF? RF. It's not frequent, but it happens. And when it happens, it's not a spasm, it's an occlusion and it's another story. I mean, you have to have your colleague ready to put a balloon in the stance and this is what happened to this patient. I'm glad you mentioned that. So you have to keep that in mind, nothing is perfect, nothing is 0% or 100% in medicine and you have to choose between spasms that are not that rare but do not translate into long-term stenosis or RF that is very rarely creating some problems but when it happens, it's almost always a stent that is needed. And you're not scared of doing the right isthmus without ice nor mapping system with the flower? Yeah. It's not difficult. The thing is, sorry, just one point. It's not designed for that purpose and it's creating way bigger lesions than what is needed. So that's a pain because you're killing too much tissue but it works very well. It's super easy, it's super fast, it works very well. I even had patients in whom I was struggling with RF, this sometimes happen, where I got a penis spline because I had nothing else at that time to finally get the block. And how many application do you use for the isthmus and the mean? So I don't know if there are any consensus here. What I'm doing is that typically one site is all you need and I'm doing six deliveries by couples. So two, two, two with rotations in between. Yeah, we do a little bit more. So I position more distant first to get to the ventricular edge and then I pull back. There's always this ridge with the SBC where you really have to flex the catheter and to get to that station ridge. And ice can be very helpful in that area. And because the catheter electrodes are so far away from each other, sometimes if you don't look by ice, you think you have contact. And because you see this huge and you think it looks great and when you look by ice, you see you're like maybe five millimeter away from the tissue. So I use ice to update. I think that's very true. The ice is very valuable, especially now that we have PFA without contact information to assess contact. Even for the pulmonary vein, I mean we haven't seen the reconnection that has been reported in Europe. And I think mostly because we use ice to assess contact when we deliver. I think that's one advantage. And obviously the same is true for the right isthmus. About isthmus, actually what Pier Gemi mentioned about the result with the Farah pulse in the metrolithmus very true. We actually have a remapping in more than 250 patient with virtually 88% reconnection. Despite acutely with the very aggressive protocol, you eliminate every record and so there is nothing. So it's clearly blocked, but chronically certainly it's not the best tool. So a Farah is really the tool of choice if you think you're gonna have to do that. I have one other question from the audience I think would be interesting. It's asking about given the similar efficacy between PFA and other technologies, why and then there's the higher risk of silent cerebral ischemia and low versatility. Why would you choose PFA in that scenario? Has this person done PFA is my question. That's like really, I know we're all academics, but do one and you're a believer and you're like even John Mandrola converted he said on the podium. So I think that says a lot. Besides also considering things that this idea, you say this fear of the silent micromolecule and this is an app and with RF as well. Actually, we reported that like in early 2000 with Transcranial Doppler with RF. So it's not unique to PFA. With PFA is unique or is more frequent based on the system you're using. And also the same with RF uninterrupted versus not. So there are a lot of nuances. So this idea that PFA is more dangerous is completely bogus in terms of cerebral embolism. So I don't really. If I may, I think this is a really important point and you may disagree on the fact that PFA is providing superior efficacy. It is simpler, easier, faster, no question. In my opinion, it also gives us more lesion durability and that should translate into superior outcomes. The champion randomized control trial is positive for superiority when it comes to PVI. This was assessed against a control arm with the cryo balloon. But the main reason for me to adopt PFA is safety. And I don't think that there is very robust evidence that it provides more cerebral damages. What I'm sure about is that it's zero PV stenosis and zero fistulas. It's over 250 cases performed in the world now and zero fistulas with the esophagus. This is a major reason, in my opinion, to favor PFA over thermal energies. Can I add something to this? Just because circling back to your question also with ice and mapping and now you're talking about durability. I think that we do not have ice and we do not have mapping, but strategically, my colleague, David Shark published in Jackie P. recently, the olive strategy. And what you can do, and this is what Pierre also says, there are no PV stenosis, so you can target the PV sleeve just by going into the vein a little bit, ablated. And what we saw is that the reconnection rates and patients coming back decreased significantly. So again, you can optimize your strategy even if you do not have mapping. So your first set of lesion is deeper than when you first started. Yeah, it's a little olive, like a little small basket you put deeper. You can even, and that's what I like about it, when you start distally and move out, you know, because of the stunning that has also been mentioned, sometimes you have no more guidance during your ablation, but when you start distally in olive, you can come back and you still see signals and you can go from a more distal to more enteral lesion and still see a little bit of what you're doing. So I kind of prefer that. Let's not forget that we are comparing thermal energies that have been optimized year after year for 25 plus years to PFA that just came in and that is only a generation one. And it's already superior in my opinion. It will keep improving because PFA is so complex. There are so many parameters you can play with that will impact both safety and efficacy that I have no doubt that what we have at present time is going to be significantly improved in the near future. Also consider that it depends on the way you look. If you look at the event, if you look at 30 second, which has been the conventional, yes, there is no difference, despite what Pierre said is true, that those are operator that use RF or cryo for 20 years versus have done one or two cases with PFA and then start enrolling patients. So clearly that's a positive asset. But if you look at the AFib burden, actually there is a superiority from PFA. So this idea that PFA is the same, it depends on the way you look. But if you look at AFib burden, actually in the event study, which is paroxysmal, it was superior. Also if you look at the FERA, the persistence study, if you look at those couple of miles, cool, they're completely separate, it missed superiority for two patients. So it's clearly a sample size issue. So this idea that is the same is not necessarily true based on the way you plan. But I think the workflow and the safety that Pierre mentioned is the plus. And so I actually, what Melanie mentioned, what I tell people, did you use PFA? When the people are skeptical, so use it and then we talk again. Because if you do one case, you see immediately the benefit in the workflow. And the fact that you don't worry about when you're doing something close to the esophagus, that makes a huge difference. And before we switch to the next question, because we have, just your setup. So because we hear about colleagues like decreasing the number of catheters, so not using a decoupler anymore, just using the fire drive with the fire pulse, for example, and ice or not. So what is your setup? If it's planned for PVI, do you use a CS catheter still or not? You know, I'd like to use it. I still, there is value in, and I still do an EP study on every patient who comes to the lab. We've seen a couple of people coming from other institutions where they missed the WPW, not WN, concealed accessory pathway. It takes two seconds. I would like to get an AH, an AHV on every patient who comes to the lab and do a quick EP study. It takes about three minutes, and it would be difficult to do without a CS catheter. And ice on everybody. We use a CS because we do fluoroscopy-guided transeptal puncture, so it actually helps you with your anatomical marker. And not every patient we give the Atropin to, if they have some sort of history, like glaucoma or something, and then it's also nice to have it. You can pace, yeah, that's the, those are our arguments. I think Musai is right, and I'm not always doing what he's doing, but I think he's right. And, well, I have to be honest. I had a couple of patients in whom, so it wasn't, it wasn't a concealed accessory pathway, but AVNRT that was not recognized by any of us before, and that happened to be the reason for recurrence. So I think you're right, Musai, we should all do that. It's the same for us. So our next discussion point is gonna be to talk about mapping and ablation strategies for other arrhythmias that you encounter during the PFA procedure. We've touched a little bit on CTI, a little bit maybe would be helpful about mitral flutter, and we have also talked about and seen more people feeling free to use PFA to isolate the SVC, and then we have that concern about where's the sinus node, and are we affecting sinus nodes? So if our panelists could address some of those questions. Okay, so maybe I'll start. For mapping, so we always say, in people who come in a FIB and do a decoupled catheter, they really help just by looking at the activation to decide what type of flutter you're dealing with, if it's perimitral, if it's right is, mostly if it's septal or roof, and really just watch the activation. So that's very simple. For us, it's standard. For the SVC, we actually published a series of 600 patients where if you use eyes again, and you put the basket at the level of the lower border of the pulmonary artery, there is no damage to the sinus node. We only use basket and no flower, because in that series, in the first 20 patients, by using the flower, we have three transients in the sinus node, because the petal tend to prolapse. So only basket, position by eyes, very effective and no risk of problem. Go ahead, go ahead. So it's the same. So if you look at patients who are booked for redo procedures, we use the Afera system, as we mentioned earlier, because you're probably gonna encounter something more than just the pulmonary veins. People who are, patients who are coming for first time ablation procedure, even if they are persistent, and even if they change to a flutter during the procedure, most of these cases are not flutters that you need very extensive mapping to do. I mean, the circuits are known for these patients. Either mitralismus flutter or CTI flutter for most of them. And we've been doing all of them with, if you're using Ferrapulse, we have not been changing. I share the concerns that Pierre and Andrea brought about the ability to create durable lesion with the Ferrapulse. We ablate a little more than what we do for other parts. So I don't know, this is a work in progress what to do with the mitralismus line with the Ferrapulse system, but we're still using it for now. I think that it really depends on your setup. So when you start single shot flutter only, and then you have atrial tachycardia or something, I think you have to be really aware if you wanna be heroic and you think you can do something, because obviously you can move the catheter around and you can entrain, you can do it at the roof. Sometimes you get lucky and like, I would say fluoroscopy guided, you could do this. But to be honest, in some cases you also have to cardiovit and see, especially when it occurs during the procedure and then you have a situation where you have isolated veins, right? You have no information about the voltage, the substrate. And I think you also have to be a bit fair to the patient here about what you can do in this setup. And I think that also guides it, but we are lucky to have now more systems coming up with mapping, right? Like the Ferra system, there's also Farview and integration and also Abbott is working on things. So I think that for those patients who you think from the beginning are more complex, you have better options now and with the emerging technologies. And we have three years left. If I anticipate anything more than PVI, I would favor working with Afira over Farpal's for all these reasons. Now, just a word on the superior vena cava. I have seen patients in whom there was clear firing from the superior vena cava, but it's not a majority far from that. In our experience it's pretty limited and I haven't seen in the literature any strong evidence that this should be systematically added to the set of a lesion, whatever the AF type is. And my real concern now that we have these PFA devices that are creating durable and massive lesions is that we over ablate our patients and take out too much cells. It's super easy to wipe out the anterior left atrium now. Should we do it? Of course not, these cells are useful and the best ablation strategy is the one that restores sinus rhythm at the least tissue cost. This is what I keep in mind when I enter the lab. We have a related question about the arrhythmia encounter. So back to the right isthmus. So it's the flutter configuration that is used mainly and Andrea talked about the reversibility. What about durability with PFA and the right isthmus? And the right isthmus. Very good with a fair, very sound reconnection but with fireballs, but with a fair, very good durability. So not with fireballs. Yeah, we use the flower only and it's easy to do, especially if you use ice. There are some reports early on with it from, I think Vivek did some studies showing that it is durable. It's easy to do, I mean the only concern is the one that Pierre brought up is the extent of ablation because you're causing but what is it like a band of like 30 millimeters. So but other than which by the way never, I never encountered a problem because of that. Maybe more theoretical problem but it's relatively easy to do. We give nitro on everybody who use ice. Can be done in very short time. I think it's important that when you do it that you do a lateral CTI line that you're not trying to go septal because sometimes you underestimate the electrical field how large it actually is. We can now see it with the FireView technology. It is way bigger than the actual circumference of the catheter. So and this is also important for SVC. That's why I would also recommend to do those extensive additional ablation, not without a mapping, especially when you're close to structures that you definitely don't want to harm like the sinus node. That's when ice would be good. Ice is very important. I understand that I agree with Pierre I mean the concern about this. I would not consider SVC extensive ablation because it's a little cube. It doesn't do anything for the, but what he said about the anterior wall, those are area where you clearly affect the mechanical function. So if you have to do it, you have to have a reason to do it and not just because you can do it. So I totally agree with that. I would say in my mind, the SVC is more relevant than the right isthmus. There's actually good evidence that the right isthmus doesn't do anything to success. Whereas the SVC is a source of trigger and it takes really like less than one minute to do it. And it really, if you do it with ice, it really has no risk, no implication. And it doesn't change. It's not like an aggressive ablation. That is a tube that does nothing to the function of the right or left isthmus. So probably more than, yeah. Going back to the CTI line, you remember that this is a large catheter. So the time, the trans isthmus conduction time, you're measuring lateral with it, correct? So the stem to the lateral wall is shorter than what you typically see. So you keep that in mind. You don't wanna keep ablating, ablating. You already have blog, but it's much shorter than when you do a septal line with a very sharp RF catheter. That's a good point. And just for clarity to understand, so the European colleagues are not using mapping in a standard case and in U.S. you are using mapping. Yes. And so when you do the SVC, you put it in basket mode, but do you map the sinus node before or not even? No, no, if you put the basket at the level of the lower border of the pulmonary artery, you are not gonna damage the sinus node. Just for the sake of clarity, I don't think any of us is doing CTI systematically to impact AF results. It's only when you have a typical flutter. And actually Andrea presented it. Maybe we don't need to do the flutter. I mean, there are now data that even people that present with flutter, if you ablate the vein, if they ablate the vein, they actually do okay. They do better than if you just do the flutter. But we also looked into our cases and what we found is in those patients that come back with atrial tachycardias, within the second or third procedure at some point, it is a flutter, a typical one. So you terminate maybe anterior and then it jumps to the, so I think the further down the road, the more re-procedures you have, you have to have that line blocked. We have workflow questions like a lot. So the first question is, do you do right veins before left veins to reduce bradycardia? Yes. Actually, that's, yeah. I mean, we do give glycopyrrolate right before a small dose, but if you don't wanna do it, probably doing the right vein before is not the best idea. We don't, it's the same protocol, start with the left, go to the right. We give 0.2 of glyco for males younger than 60, older than 65, and 0.4 for everybody else, just because it can cause some urinary tension. And if you do that, you don't get any bradycardia. The other related question, practical aspect, is how many application is your max limit? Until the job is done, yes. No, but regarding, I guess, the point is the hemolysis aspect of it. I think that we're really, maybe different approaches here on the panel, I would say. That's your opinion. I think once you have a patient on the table, you have to do what you need to do for that patient. Obviously, so again, I think now that we have option, if you have a patient, like Pierre mentioned, that has some degree of pre-existing kidney injury, those are the cases for afera. Afera create dismal hemoglobinuria. You don't have to worry about anything. If you use Farapulse, you either limit, so this idea that if you limit the number of application will keep you safe is wrong. Because if you have a patient with a creatinine of 1.5, even 40 application will cause kidney injury that can end up requiring dialysis. So this generic term that limiting the number is the safe way to do is absolutely wrong. If you hydrate the patient properly, you can do as many lesions as you want without any problem. So I think you have to decide what is good for the patient and do the right thing. We follow the same protocol that Andrea described probably about a year ago. We give a lot of fluids. We give one liter during the procedure, one liter after. We never had a problem. We give Lasix for someone who we worried about heart failure but was very aggressive with fluid management. And again, we never had a problem. Large number of cases. I would maybe jump in here. I think we need a more differentiated view on this, to be honest. So first of all, what catheter are we using and how much does it impact hemolysis, right? Because when you have contact with that catheter, you just have a lot of blood going through the catheter in the electrical field. So you destroy your red blood cells. When you add fluid, you just change the proportion of it but you still cause the harm to the red blood cells. And we do not know if this is, at the end, not hurting the clomerulus at all or if this is just making the lab look better. No, no, no. We know. I mean, there is literature from the post-CABG that hydration is the way to prevent clomerular damage from hemoglobin reaction. No, but also we have extensive literature from muscle-induced injury, from crash injury. And these typically don't lead to any long-term kidney effect. There's absolutely no effect. Well, except that this is for kidneys. The amount of hemolysis is the same, okay? Whatever hydration. I'm not saying you shouldn't use it. Of course you should. It protects the kidney, fine. But if there are other consequences of the hemolysis, they will not be impacted by hydration. The point is that we haven't seen it. And, well, I don't know about that. I'm not so sure. I mean, this hemolysis is, in fact, impacting the hemostasis. And so possibly we have an easier formation for clots. There has been stroke, very few of them. But we can't be sure at this stage that it is not related. No, but it's not an issue for us because we do every procedure on uninterrupted blood thinning. I think if you stop the blood thinning, maybe that could be an issue. But, I mean, as I said, it's a practice issue. But to be honest, we haven't seen any problem with the hydration, even in terms of strokes. Yeah, I agree, I agree. We've never seen a problem. I mean, even spasm could be impacted by hemolysis through nitrite oxide. So, I mean, yes, that's the basic science behind it. I have no demonstration that it's a mechanism. But we should probably consider that as an area of some uncertainty. And a related question for the workflow, the ACT target. Has it changed since you've been using PFA? I mean, it's always been our practice. So, as Andrea said, uninterrupted anticoagulation, ACT 350. We've addressed it with the ACT 350 to 400 is our standard for whatever we use. We use over 300. The only thing we've changed is because it takes us about, from puncturing the groin to being in the left, it takes about five to seven minutes. So, we changed the workflow that we administer the heparin before we puncture the groin now because we're just so quickly in the LA. And we use ultrasound for the groin puncture that works really well. But that's how we changed it. It's just, there's no sense in waiting today for the ACT to get up and then like, you know, the procedure is so short. And that's what happens when you participate in the trials because then you can't go to the left until you have that, or you can't introduce the catheter until you have a certain ACT level. I'm doing the same. And I think it was you, Andrea, about publishing some data about clotting on the transeptal sheath that I was pretty impressed with. And since then, I use heparin injection even before I get to the lab. So, I just have to be active and I can check my ACT before puncturing, in fact. Okay, good. Why don't we move on? Okay, so our next topic is gonna be to talk about indications and practical aspects of concomitant left atrial appendage closure during AF ablation procedures. And this, I think, is a big issue in the United States. We have a new code that allows us to do both closure and ablation at the same procedure time, which is a code that is well-imbursed by CMS. And so, I think we're gonna see a push, at least in the US, for this sort of procedure. So, could you talk a little bit about how you're incorporating that into your practice, which of the patients that you're choosing to close at the same time, and the sequence in which you do it, ablation followed by closure? So, we're using it more. And we're still not at similar to the population that we enrolled in the option trial. So, it's not like everyone. So, the people, the patients who we're doing it on, anyone who we expect bleeding, or anyone who we expect they're gonna have issue in the future with anticoagulation, we don't do it. And I don't expect we will ever do it in patients with low CHAS-VAS score, because we are able to stop anticoagulation in a large number of patients after ablation. I mean, we monitor people for a year, and many of them, we can stop anticoagulation. So, the folks we are doing it on are patients who are expected to have trouble with blood thinners, or where we isolate the left atrial appendage. And you're stopping anticoagulation based on a CHAS-VAS score for those patients? For the first group I talked about? Yes. Yeah, usually everyone who didn't have a score, which usually didn't have a stroke before CHAS-VAS score two or three, we monitor them for a year. And after a year, especially if someone has an Apple Watch or something, we are comfortable stopping blood thinners on everyone. So, I think it's really, you don't wanna stick a watchman in someone who you're gonna end up stopping anticoagulation. Where we do it, we do it during the procedure. So, we use ice for it. And it's a learning process. It's not easy initially to do it with ice. You can plug it initially and you think you're great, but after that, you realize that you may have some leaks. So, you need to spend some time on it. It's more difficult than doing it with TEE. The view that helped us, we put the ice as a mital isthmus, look up, you can create a view equivalent to the 135 angle of TEE. And it's, once you get used to it, it adds about maybe 15, 20 minutes to a case. So, that means you put your ice on the left side? Yes, yes. In cases of PFE, even if you don't know the effect. No, no, no, just for this. So, let's say you're doing it with a Ferrapulse. You finish your procedure. You leave a wire. You remove your ablation sheet. You put your watchman sheet. And then you pull it out. The watchman sheet may be a little bit bigger maybe. So, you pull it out and then you put next to it the ice. And the same, we use the same hole, one hole for both. And then you advance your sheet again to the left side. Can I ask you all here a question, which I'm wrapping my head around? So, in the option study, and it was presented by Dr. Zaliba at Bosnia-Herzegovina Symposium, the data about concomitant or sequential. And the data looked really good on the long-term follow-up regarding stroke rate was really low and preventing pleading with the concomitant approach. And then there's like a little registry published in HeartRhythm by Dr. Tam that shows that they had three groups. One group was LAAC only, one group was PFA ablation only, and one was concomitant. And they saw due to edema most likely that they had more peri-device leaks in the concomitant case where they had probably edema of the ridge. So, I wonder, because we talk so much about those peri-device leaks, how they can impact. But from option, we don't see that there's a clinical relevance to it maybe because there were peri-device leaks in the study. And we know they occur when you do it concomitantly, maybe even more so. Should we just ignore them? No, I don't think we should ignore them. I mean, we said we. To be honest, we haven't seen that in the concomitant cases. I mean, our approach is a little bit different because we tend to over-compress the watchman. So maybe that's the reason, but we don't see any increased rate of leaks. Yes, this has been our experience so far. Our strategy with the watchman device is to basically put in the biggest device you can do as if the depth allows you, not just based on what the orifice is. I believe there's value in reducing leaks with oversizing watchman devices. Okay. And we have a related question regarding that. So in concomitant procedure, what can you discuss the anticoagulation strategy after? So with PFA, we have gone to half dose the day after the procedure, and then they stay on half dose until three to six months. And then at that point, we decide if they switch to baby aspirin or stay on half dose long-term based on risk factor that we have seen to impact the potential risk, like a big left atrium, history of cancer, obviously if they have plaque in the aorta, those are sort of things that make us keep them on half dose but we go to half dose the day after, and we're done. Half dose of NOAC. Half dose of NOAC, yeah. I treat them like a PVI. So full dose anticoagulation for three months after the procedure. Okay. And then you stop. Just. No antiplatelet. No, no aspirin. And that's based on the data from SURPASS study. SURPASS is about 66,000 patients from the NCDR registry that showed that the best regimen for Walshman procedure is DOACS alone. It's better than DOACS plus aspirin. I think with PFA, we need to, we're gonna, I mean, we just actually published a paper in Aridum showing that in a standard case, it's actually safe to stop blood thinner after one month because there is no endothelia. Whereas if you do the same with RF, you have a higher rate of stroke. So I think it's a work in progress, obviously. But so far, with the Walshman, we haven't had any problem with just half dose from the day after. We have stopped doing baby aspirin for a long, long time. So we've discussed that a bit, the redo ablation procedure. You mentioned that you would use Afera instead of Firepulse in your case for redo procedures. What about ablation strategies? So this is touching also that the last discussion was about persistent AF and we have many questions about that. So if you go in your case, it's beyond PFA, we've talked about PFA a lot in this session, but let's say the strategy, your veins are isolated in your redo case, then what? And in the recurrence, it's AFib, not flutter. You know, I think this is now the biggest unmet need in EP and there are a couple of studies starting out. We're doing a study with Boston Scientific, it's a rematch study. So we use, so for technology-wise, we'd like to use Afera for these cases because most of them, I end up doing more than the veins. So even if the veins, some veins are reconnected, I should just do more than that because you don't wanna, especially if they are persistent, you don't wanna bring this patient again for a third procedure. So I do the posterior wall plus the pulmonary veins on everybody and most recently, I've been doing more, especially for persistent and that's based on, you know, it's anecdotal, based on our experience from the SPHERE study. In SPHERE study, on all our patients, couple of centers, so ended up being about 30% of SPHERE. We did mitral isthmus plus CTI plus pulmonary vein plus posterior wall and this is kind of simulate the Marshall Plan that Pierre described and if you look at the results from, we presented that earlier today, as a result of patients who received linear ablations in the SPHERE studies, there was a trend toward better outcome. It didn't reach statistical significance because we didn't expect it to, first of all. It's a small number of patients and the study was not powered for that. But I believe there's value in doing these lines in a redo procedure. So this is kind of, we're kind of like veering toward that as our strategy for redos. And you would do with a FHERA? Yes. And if you don't have a FHERA available, what would you do? I have it, so. Before that, I think the best thing you can do is just enroll in clinical trials, that's the best option you can do. And I think not to forget AF source mapping, now that we have powerful tools for ablation and we believe we can produce better lesions. We have to think about those things again. And I agree, like every, in an ideal world, all of those patients should be in a study because we don't know. But there's Volta, there's Cortex, there's some things the industry's coming up with. And I think we should have an eye on it and combine it with the best ablation, strongest ablation tool we have and then come up with strategies. And Pierre, what about the Marshall Plan with PFA? Yeah, so, well, first of all, we just recently presented at the ERA and I did it this morning as well, the results of that randomized comparison for persistent AF, where we had a control arm with PVI and investigational arm, the Marshall Plan, which is PVI plus roof plus mitralismus and alkalization of the vein of Marshall, knowing that this was done before PFA availability. So that's a RF trial, it's a major limitation, yet it was positive. It's a 20% benefit in the Marshall Plan arm. So for persistent, this remain our approach with the caveats that we all agree that a sizable proportion of patients with persistent AF are going to be fine with PVA only. And the challenge is to identify those patients and to decide in whom we should go beyond just PVI. Now, the situation you describe, as Musa said, is you're in trouble. I mean, you have AF recurrences, not to say that the patient is in AF at the time of relation, but he had recurrences, and yet the veins are isolated. What to do? Well, we're kind of clueless. We sometimes, and I tend to do that, pre-systematically use isoproteinol to see if there is something focal that can be mapped. Initiation, that's always a very uncomfortable procedure, in my opinion. The heart is banging all over the place and catheter instability is major, et cetera. Plenty of limitations, but still do it, and sometimes we have a clear initiation that we can figure out. And you use PFA for the non-PV triggers? And we would work preferentially with the AFERA in this context, so yes. The thing I've noticed, which can perhaps help, I don't know if you share that, but in some patients, the recurrences are triggered by exercise. And when this happen, I have noticed that vein of martial alkalization, in fact, could be helpful. So like if some triggers were coming from the vein of martial in the context of adrenergic initiation. And then if I have no clue with isoproteinol or no other insights, I would deliver the lines, as Musa said, because I have no better option, but I'm not happy doing that, because I know that a reasonable number of patients will not respond to that approach, and yet they have the damage. And there's a question regarding the lines, so the mitral isthmus line. Do you do anterior, or do you do at the mitral isthmus? No, anterior, it has always been the last option to me, in my opinion. I mean, only if there is a very significant remodeling on the anterior wall with a significant scarring there, I would consider doing it here, because it impacts the activation of the left atrium after ablation very significantly, so you get the left atrial appendage kick that happens after a QRS in some patients. It's not good for the hemodynamic, so my favorite position is the initial one that we described years ago. That's very important, because people don't realize, but it does delay the appendage, so you really sort of almost create an uncoordinated contraction. And it's longer, twice as long. But again, the point that Pierre made is important. Many, it's actually not uncommon to have patients with significant anterior wall scar. And the worry, if I do a posterior line, they still have sometimes that flutter from that area. So if they have significant scarring, I do an anterior mitralismus line. For us, the approach has been more non-PV trigger since the early 2000s. We haven't sort of abandoned that. So what Pierre mentioned with the high dose of isoprothyron, there is a way to do it so that you enable that banging by using the gluteal capillary to explode an electrode. But there are patients where that doesn't show anything, as Pierre mentioned, and those are people where we usually do mostly what Pierre and Moussa mentioned. We do the posterior wall, you know, when you do the lines, you do that. The posterior wall with the mitralismus, we make sure the SVC is isolated. And sometimes we do the CS. The appendage become the last thing. So if they come back after all of that, then the appendage become the target. We also have patients, if I may, where because of the delay for redoing the appendage and the ablation, we notice that they spontaneously improved over time, over months. And sometimes it's good to, you know, give the patient a little time to maybe see what the spontaneous evolution is. And there are patients in whom it's the opposite. They would increase their burden, but not all of them. Good. I think we are at our time limit. I'd like to thank our speakers, really lively conversation, and the audience for all your good questions. I'm sorry we couldn't get to all of them, but thank you so much. Thank you.

atrial fibrillation

AF ablation

pulmonary vein isolation

pulsed field ablation

Laurent Max

Susan Eisenberg

procedural workflows

safety concerns

intracardiac echocardiography

anticoagulation management